Provider Demographics
NPI:1063383024
Name:GERAGHTY, SHANNON ANNA
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ANNA
Last Name:GERAGHTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 ECCLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-1819
Mailing Address - Country:US
Mailing Address - Phone:925-542-0354
Mailing Address - Fax:
Practice Address - Street 1:2380 SALVIO ST STE 301
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2143
Practice Address - Country:US
Practice Address - Phone:925-692-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program